Healthcare Provider Details

I. General information

NPI: 1710407960
Provider Name (Legal Business Name): ALANA A GILLENWATER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 RESTON PL
GASSAWAY WV
26624-9356
US

IV. Provider business mailing address

3942 DAVIS STUART RD STE 3
RONCEVERTE WV
24970-0269
US

V. Phone/Fax

Practice location:
  • Phone: 304-364-9191
  • Fax: 304-364-9193
Mailing address:
  • Phone: 304-647-3987
  • Fax: 304-647-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT003799
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: